wiseGEEK: What is Health Insurance Fraud?

Fraudulent behavior may loosely be defined in the health insurance context as any behavior designed to solicit money to which a person or group is not entitled. There are so many kinds of health insurance fraud it would be difficult to list them all. This is especially the case because fraud involving health insurance is perpetuated by a variety of sources, including health insurance companies, insurance brokers. unscrupulous doctors, chiropractors, allied health professionals, medical institutions, and patients.

Some examples of institutional or health professional led health insurance fraud include the falsification of information on forms. This is not always meant for the personal benefit of the health professional or the institution. Sometimes a doctor will omit information on forms that would lead a patient to not get treatment because of a pre-existing condition, or a hospital will change the time of admission slightly so a patient isn’t charged for a whole day. Though these actions are well meaning, they are nevertheless fraudulent because they do not make an accurate report to the patient’s insurer.

Intentional health insurance fraud does not even have this excuse of trying to help a patient. Instead, doctors, allied health care workers or hospitals may file false claims, claim treatments for patients that never occurred, fill prescriptions under patients’ names and then sell them on the black market, diagnose diseases that do not exist, and order unnecessary testing. Occasionally, a medical worker works in collusion with a personal injury attorney to falsify medical reports, in which case more than one type of insurance fraud may be perpetuated.

Health insurance companies or brokers may also commit various forms of health insurance fraud. The biggest

of these is not paying on legitimate claims. Some companies may intentionally deny payment in the hopes that claimants will not protest the treatment. They could also deny based on reasons that are unfounded or illegal, but can reverse their decisions if people bother to investigate the denial. Routine misrepresentations of coverage may fall under the health insurance fraud umbrella too. When insurance representatives do not truthfully disclose information on what is covered, which can happen, they may be defrauding their customers by avoidance of payment, or by discouraging customers to get treatments they need, which truly are covered by their insurance.

Alternately, some “health insurance companies” or “brokers” are not truly legitimate and are instead scammers looking to make a quick buck on people who are desperate for health insurance. They have no intention of paying claims and merely want to collect their money. An additional type of health insurance fraud is making false claims about what is being sold. For instance, health discount plans are not insurance. When they are represented as insurance, this may be a fraudulent act. Selling insurance in a state in which a company is not licensed to operate is fraud too.

Lastly, patients can commit health insurance fraud in a variety of contexts. They could make false claims about illnesses for any number of reasons. If an insurance company demands any form of physical, and a patient doesn’t provide accurate information, this could be viewed as fraudulent and might void any coverage. Also, patients who are willing participants in the fraudulent acts of physicians or facilities that misreport information are a party to fraud and could be prosecuted.